Advances in Outpatient Foot and Ankle Surgery

Minimally invasive techniques, premium power tools and innovative multimodal pain management practices are helping surgeons repair a number of foot and ankle problems that result in less post-op pain, earlier ambulation and positive outcomes. These four procedures in particular are becoming more popular in outpatient ORs:

• Ankle ligament reconstructions. Lateral ligament instability via direct repair of the ligament using suture only is normally sufficient, but less effective in patients with failed index repairs or particularly weak ligaments. Newer anchor-to-anchor suture construct technology allows surgeons to use a strong nonabsorbable permanent suture that is directly anchored to the two bones they’re trying to hold together. One anchor is placed in the fibula, the other is placed in the talus and a permanent suture connects those two anchors that substitutes for the ligament.

• Minimally invasive bunionectomies. Several companies have recently introduced minimally invasive techniques to correct bunions that result in small incisions, decreased postoperative pain and improved cosmesis. These techniques are performed through two to three tiny poke holes in the foot of less than 0.5 cm each. The surgeon then uses low-speed, high-torque burrs to straighten and remove the bunion bone.

• Achilles tendon repairs. The surgery is performed through a much smaller incision using a minimally invasive technique where the surgeon makes a single 1 cm to 2 cm incision on the posterior aspect to the ankle and passes the sutures in a percutaneous manner, minimizing the surgical exposure. The smaller incision decreases the potential for infection and increases the potential for successful wound healing.

• Fixation of osteoporotic ankle fractures. There’s been a game-changing technology introduced into orthopedics called the locking screw. With this technology, the screw binds to the plate at a fixed 90-degree angle, which creates a construct that is far superior biomechanically, in that the plate and screw are able to hold weak osteoporotic bone with great strength. These locking screws have enabled surgeons to fix osteoporotic ankle fractures with much greater predictability and success. 

The power tools surgeons use to execute foot and ankle procedures — saws and drills — are traditionally high-speed and low-torque. They pose a risk to nerves and vessels if they come into contact with those soft tissues, so surgeons must use additional devices such as soft tissue retractors and drill guides to lessen the risk.

However, surgeons have gained an additional aid in their efforts to protect soft tissue. A recent advance in the area of power tools for foot and ankle procedures is the low-speed, high-torque burr. It poses much lower risk to soft tissues because it typically pushes nerves and vessels out of the way rather than cutting them. The low-speed, high-torque burr, fortunately, is still excellent at cutting bone, and it has facilitated minimally invasive bone surgery for foot and ankle cases. Because of this much safer power tool, surgeons can make tiny poke holes and let the burr push soft tissue out of the way, as opposed to making large incisions and retracting that tissue. This advance has been revolutionary, and it has enabled the execution of procedures such as the minimally invasive bunion surgery.

Postoperative pain control, wound problems and potential infections are particularly challenging for foot and ankle surgeons to address, but progress is being made in those areas.

• Pain management. In many foot and ankle surgeries, the regional blocks anesthesiologists use tend to wear off after about 12 hours. Fortunately, though, the ability to perform many more of these procedures in a minimally invasive fashion reduces the amount and intensity of the pain patients might have experienced with more traditional approaches. Surgeons are particularly excited about minimally invasive technology for bunion and Achilles tendon repairs because of the potential to expose the patient to less pain immediately after surgery.

Different surgeons handle postoperative pain management differently. I’ve largely adopted the protocols of my hip and knee reconstruction colleagues: a multimodal approach that minimizes opioid use and takes advantage of medications such as nonsteroidal anti-inflammatories, acetaminophen and the nerve medication gabapentin. By using three non-narcotic classes of medications, patients need narcotics only to treat breakthrough pain.

• Wound closure. In open foot and ankle surgery, wound closures are typically performed with an absorbable subcutaneous 3-0 suture followed by a skin closure with a nonabsorbable suture such as nylon. When surgeons perform minimally invasive procedures with much smaller incisions, however, they can avoid closing the subcutaneous layer; they need to close only the skin layer, a practice that saves suture as well as time.

• Infection prevention. Because the foot and ankle are the farthest from the heart of any part of the body, they have the worst blood supply. That’s particularly problematic because blood is what brings the immune system to those extremities. That translates to a higher rate of infection in the foot compared to in the knee or the hand. As a result, surgeons exercise particular caution during surgery to maintain the sterility of the surgical field. They also perform a very thorough preoperative skin preparation that includes flossing between the toes with alcohol-soaked gauze, followed by a chlorhexidine scrub.

Nevertheless, infections still occur. We largely believe the potential for infection is associated with the size of the wound as well as the duration of the surgery. Minimally invasive techniques come to the rescue again here. If we can move through the surgery quickly and in a minimally invasive manner, we have the best chance of minimizing the risk of infection. OSM